Infection Control & Hospital Epidemiology
Table 1. Impacts of the Clostridioides difficile Computerized Clinical Decision Support (CCDS) Tool and Incentive on Testing and Infection Events Total Tests/HO-CDI
Component Prevented testsa
Completed C. difficile NAAT tests Negative
Duplicate negativeb Positive
Duplicate positivec HO-CDI LabID events
Pre 0
3243 2649 80
502 12
190
Post 959
1893 1541 23
325 4
129
Note. NAAT, nucleic acid amplification test; HO-CDI, hospital-onset C. difficile infection; Pre, preintervention period; Post, postintervention period. aIdentified as a test order opened by a provider, triggering the CCDS, but without a completed order. bWithin 3 days following a previous negative result. cWithin 14 days following a previous positive result.
% Reduction …
41.6 41.8 71.3 35.3 66.7 32.1
243
Table 2. Cost Analysis Annual Component Costs Component
C. difficile NAAT Laboratory cost
HO-CDI LabID events Financial incentive
CCDS technology build
Component Volume, No. Pre: 3,243 Post: 1,893 3min per test
Pre: 190 Post: 129 775–800 House staff 10 h
Unit Cost/Wages $31.36 per test
Lab technologist: $27.60/h10 CDI attributable cost: $6,326 0.8% salary bonuses: $433–569 Programmer: $100/h Total
Pre
$101,700 $4,475
$1,201,940 … …
$1,308,116 Post
$59,364 $2,612
$816,054 $367,561 $1,000
$1,259,244
Cost Savings, $ $42,336 $1,863
$385,886
− $367,561 − $1,000 $61,524
Note. NAAT, nucleic acid amplification test; HO-CDI, hospital-onset C. difficile infection; Pre, preintervention period; Post, postintervention period; h, hours. Cost differences reflect preinterventionminus postintervention periods with the exception of technology-associated build time, which was factored under the postintervention period for this analysis.
HO-CDI (previously reported)6 but resulted in a significant overall savings for the health system despite the considerable initial cost of the incentive. Cost savings could be considerably greater in subsequent years without the expense of the bonus, if the tool remains effective in guiding test utilization. Nonetheless, the study has several limitations. First, the primary goal of our intervention was to improve
patient care by reducing inappropriate tests and potential harm attributable to overtreatment, which accounted for the largest proportion of estimated savings. However, it is imperative to understand not only the benefits but also the potential harms of reduced C. difficile testing. Further studies are needed to explore the overall effectiveness and safety of the diagnostic stewardship interventions for C. difficile assessment. Second, HO-CDI events were chosen as a convenient esti-
mate for reduction in treatment for CDI; however, reductions in HO-CDI did not necessarily reflect prevention of CDI treat- ment in all patients and may have over- or underestimated savings. For example, we did not factor community-onset or recurrent CDI, which may cost up to $10,580 per case.9 Other “hidden” costs, such as added provider time and administrative/ quality improvement efforts, were not included. Also, savings
associated with avoidance of reimbursement penalties or improved institutional reputation/rankings were not factored in the analysis. Finally, pharmaceutical costs were not calculated separately
from estimated attributable costs because nearly all patients were treated with oral vancomycin compounded by the hospital pharmacy. The cost analysis of a CCDS diagnostic stewardship tool like
ours will be impacted by institutional decisions regarding C. difficile infection testing and alternative treatment protocols. As such, this report should not be viewed as a cost-effectiveness analysis but rather as an assessment of costs and estimated cost savings of the CCDS tool at our institution. A financial incentive may not be feasible at other institutions; however, the specific contribution of the bonuses to this diagnostic stewardship inter- vention is unknown. Reduced testing has been sustained for at least 12 months following distribution of the 1-time financial incentive for trainees in June 2017. In addition, trainees com- prised only about half of the prevented tests; other ordering providers received no incentive. Although experimental and financial evidence support the use of diagnostic stewardship to improve C. difficile diagnostic
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